Latex hypersensitivity in spinal cord injured adult patients

Latex hypersensitivity is a major cause of anaphylaxis during anaesthesia. Patients with spina bifida, health care or rubber industry workers have been considered at risk for latex sensitization. By analogy, the existence of other at-risk subsets of patients with latex exposure due to frequent surgical procedures has been suggested. The aim of this study was to evaluate the prevalence of latex sensitization in a cohort of adult patients with spinal cord injury and repeated latex exposure. Forty-two adult patients with spinal cord injury were studied and retrospectively compared to a group of 30 children with spina bifida evaluated using a similar protocol. Patients were administered a questionnaire concerning history of latex hypersensitivity, atopy, and surgical procedures. Latex sensitivity was investigated by skin prick-tests and latex-specific IgE assay. The search for atopy was based on in vivo and in vitro tests against a panel of environmental allergens. No chronic spinal cord injured patient had a history of latex allergy. When compared with spina bifida, the number of surgical procedures was not statistically different. Although not significantly different, the prevalence of atopy was higher in spina bifida patients. The high level of latex sensitization in spina bifida patients contrasted sharply with the absence of sensitization observed on both skin and in vitro tests in patients with spinal cord injury (P<0.0001). This study confirms that adult patients with chronic neurologic defects resulting from spinal cord injury exhibit a low risk of latex sensitization. These results suggest that considering adult patients with repeated surgical procedures as a group at risk for latex sensitization because of a high degree of latex exposure should be re-examined.     

Spina bifida as an independent risk factor for sensitization to latex.

PURPOSE: Patients with spina bifida are at a high risk for having an immediate type allergy to latex products. The number of surgical interventions, atopy and catheterization are well known responsible factors, whereas the condition of spina bifida per se has not been established as an independent risk factor. MATERIALS AND METHODS: A total of 131 patients with a shunted hydrocephalus (48 with spina bifida and 83 of other origin) were investigated for sensitization to latex by skin prick tests and determination of specific IgE. We hypothesized that the diagnosis of spina bifida will increase the risk for latex sensitization while considering potential confounding factors. Thus, we performed a multiple logistic regression analysis to determine independent risk factors. RESULTS: Whereas 56.3% (27/48) of children with spina bifida proved sensitized against latex, this result was the case in only 16.9% (14/83) with another cause of hydrocephalus (p <0.001). The mean number of surgical interventions was 6.2 for patients with no latex sensitization and 9.3 for those with sensitization (p = 0.02). Of patient sensitized to latex 43.9% had a history of atopy compared to 15.5% of those not sensitized (p = 0.02). Sensitized and nonsensitized patients were comparable regarding gender and catheterization. In a multiple logistic regression analysis the cause of the hydrocephalus (odds ratio 6.76 for spina bifida), atopy (odds ratio 3.37) and the number of surgical interventions (odds ratio 1.14 per operation) were identified as independent risk factors. CONCLUSIONS: The increased risk of latex sensitization in patients with spina bifida seems to be disease associated. Possible explanations for this finding may be genetic, antigen mediated, early latex exposure and immunological reasons.     

Latex allergy in spina bifida patients

Latex allergy has become a major problem in children with spina bifida, who need to undergo many major aggressive diagnostic and therapeutic procedures. Latex allergy is increasing in medical and surgical practice. Although early reports of latex allergy date from 1927, only over the last decade there has been more attention paid to latex allergy. This is due to an increasing number of reported cases of mild to fatal adverse reactions to latex. Risk groups have been identified; among these are patients undergoing multiple surgeries such as those with spina bifida. In this critical review, we aim to emphasize some aspects of the current management of surgical patients with latex allergy.     

Latex allergy

Allergy to natural rubber latex affects people routinely exposed to rubber products. Groups thought to be at highest risk include atopics, health care workers, rubber industry workers, and individuals who have undergone multiple surgical procedures, especially those with spina bifida. Allergy to latex is a type I, immediate, IgE-mediated reaction that can lead to anaphylaxis and death. The prevalence, risk factors, clinical manifestations, diagnosis, and management of latex allergy are summarized in this review.     

Latex allergy in children with urological malformation and chronic renal failure

PURPOSE: Children with spina bifida, bladder exstrophy and anorectal anomalies are at risk for latex allergy. Severe intraoperative anaphylaxis in a boy treated with kidney transplantation prompted this study to evaluate the prevalence of latex allergy in a cohort of children with chronic renal failure (CRF). MATERIALS AND METHODS: Between 1996 and 2002, 57 boys and 28 girls were investigated at a median age of 10.5 years (range 1.3 to 22.9). Urological malformations were the underlying cause of CRF in 33 patients (39%). Of the patients 39 were on conservative treatment, 20 were on dialysis and 26 had a functioning renal graft. Latex reaction was assessed by a careful history, specific serum latex IgE and skin prick test. RESULTS: A total of 19 patients (22%) showed latex reaction, of whom 8 had allergy (clinical symptoms included severe intraoperative anaphylaxis in 1) and 11 had sensitivity (positive IgE or prick test without symptoms). Of these 19 patients 11 had urological malformations. The number of surgical procedures, young age at operation and atopy were significant risk factors. When operations were analyzed separately, ie urological vs nonurological surgery, only urological surgery was significantly associated with latex reaction. A significant correlation was also found between the overall number of operations and latex radioallergosorbent class. CONCLUSIONS: All children with CRF who undergo early and multiple urological surgery are at high risk for latex reaction. Primary latex prevention, ie the routine use of latex-free gloves, tubes and catheters, should be implemented in all children with complex urological malformations.     

Anaphylaxis to ethylene oxide – a rare and overlooked phenomenon?

Spina bifida patients have been reported to be at increased risk of anaphylactic reactions during general anaesthesia. Following a reaction, latex is often incriminated as spina bifida patients are known to have an increased incidence of latex allergy. Ethylene oxide (EO) has recently been suggested to be an alternative cause, but in many cases reported in the literature, it seems that EO has not been considered as a cause. EO is a highly reactive gas widely used to sterilise heat-sensitive medical devices, and traces of EO can be found in many of the same products as latex. We present the case of a spina bifida patient with a known latex allergy, where EO was found to be the cause of an anaphylactic reaction during general anaesthesia. In addition, we describe measures taken during preparation of a subsequent general anaesthesia to minimise exposure to EO. Spina bifida patients seem to be at increased risk of sensitisation against EO due to repeated exposure, but only limited literature is available. To ensure that EO is considered as a cause in these cases, we recommend that testing for latex and EO go hand in hand following an anaphylactic reaction in this high-risk population.     

Intraoperative anaphylaxis to latex

This case report describes intraoperative anaphylaxis occurring in a fourteen-year-old female with spina bifida in which latex surgical gloves were incriminated as the aetiologic agent. The patient was non-atopic but since eight years of age she had developed localized angioedema and urticarial skin reactions on exposure to rubber. She had previously undergone several uneventful surgical procedures. Forty-five minutes following induction of anaesthesia and during laparotomy for elective cholecystectomy she experienced sudden onset of increased airway pressure, oxygen desaturation, tachycardia, profound hypotension and erythema consistent with an anaphylactic reaction. Resuscitation with manual ventilation and oxygen, intravenous fluids and an epinephrine infusion was successful. Subsequent investigations for allergies demonstrated a strongly positive skin prick test and RAST to latex antigen, with negative results to anaesthetic agents, antibiotics and inhalant allergens. During two later operations prophylaxis consisting of diphenhydramine, ranitidine and hydrocortisone appeared to prevent further reactions. Latex should be considered as a cause of life-threatening intraoperative allergic reactions in patients with a history of rubber allergy or frequent exposure to latex products.     

Latex allergy--a clinical perspective

Latex allergy has been increasingly recognized in the past 6 years. Defined risk groups are health-care workers, spina bifida children, and possibly food allergy patients. Powdered latex gloves and latex barium enema tips are products most commonly associated with allergy. Clinically, patients present with contact urticaria, allergic rhinoconjunctivitis, asthma, and anaphylaxis. At least 15 deaths are reported to have occurred because of latex allergic reactions. Severe occupational latex allergy can result in removal of the affected individual from the workplace. This will have important cost implications. The only presently available treatment of latex allergy is avoidance.     

Association between Latex Sensitization and Repeated Latex Exposure in Children

Background: Children with spina bifida are at greater risk for latex and ethylene oxide sensitization. The authors' aim in this study was to evaluate the role of previous surgical procedures in the development of sensitization to latex and ethylene oxide.

Methods: The authors investigated 80 children 1-16 yr old, separated into 3 groups. Two groups had a history of 3 or more general anesthetics: 29 children had spina bifida (spina bifida group) and 31 had undergone multiple surgeries for another disease (multiple surgeries group). A control group of 20 children had undergone less than 1 anesthetic. Clinical manifestations with latex, perioperative anaphylactic reactions, and number of previous anesthetics were recorded. Skin prick tests with a commercial extract of latex, four common inhalant allergens, and radioallergosorbent test to latex and ethylene oxide were performed.

Results: The three groups did not differ significantly with respect to age, sex, and atopic status. Mean number of anesthetics was comparable in the spina bifida and the multiple surgeries group. Latex sensitization was common in the spina bifida group (59%) and in the multiple surgeries group (55%) but not in the control group (0%, P < 0.05). Ethylene oxide sensitization was significantly more frequent in the spina bifida group than in the multiple surgeries group (44% vs. 19%; P = 0.052) and strongly associated with latex sensitization. Mean number of previous anesthetics was greater in children sensitized to latex (8.4 vs. 3.9; P < 0.05).     

Intraoperative anaphylactic reaction due to latex hypersensitivity.

Severe anaphylactic reaction secondary to latex allergy has lately been recognized and reported especially in individuals with spina bifida. We report a case of severe intraoperative anaphylactic reaction due to latex allergy. Preoperative testing for latex allergy may be helpful in determining latex allergy. We suggest a preoperative management protocol for patients who are thought to have latex allergy. An increased awareness to latex allergy will help avoid this potentially catastrophic event.     

A case of latex allergy caused by hypersensitivity to the latex-containing facemask

We experienced anesthetic management of a 2 year-old girl with Pierre-Robin syndrome. She had received respiratory support for 6 months from the birth. As soon as we induced general anesthesia, she had a skin rash. We suspected that this rash was caused by hypersensitivity to the latex-containing facemask. We stopped anesthesia and postponed operation. After a month, operation was performed under general anesthesia using latex-free anesthetic circuit and equipments. Perioperative course was uneventful. Since the first report in 1979, the number of patients with latex allergy has progressively been increasing. It has been reported that latex allergy occurs in persons considered at high risk for latex allergy including patients with spina bifida, urogenital abnormalities and atopic dermatitis, and in health care workers and rubber industry workers. If patients suspected of having latex allergy undergo surgical procedures, anesthesiologists must check patients' past history and possibility of chronic exposure to latex products. In these cases, preoperative preparation is essential and thorough precaution should also be taken to avoid life-threatening allergic reaction.     

Parameters of gas urethral pressure profiles: Part I.

Carbon dioxide urethral pressure profiles were analyzed under the same conditions for 113 spina bifida and 87 non-spina bifida patients categorized by sex and age. Either duplicate or triplicate measurements were obtained from each patient for parameters of continence length, closure pressure and functional length. The degree of reproducibility of each parameter varied depending on age, sex and diagnosis. Except for 1 age-sex category closure pressure exhibited the smallest degree of relative variation for spina bifida patients. Results for non-spina bifida patients were mixed in that the measurement of no one parameter resulted in a uniformly smallest degree of relative variation. Reproducibility based on within patient variability generally was least for the continence length.     

Latex allergy in children: modalities and prevention

Allergic or immediate hypersensitivity reactions to latex have been reported in children with increasing frequency in the past. The reported prevalence varies greatly depending upon the population studied and the methods used to detect sensitization. Children's subpopulations at particular risk include: atopics, individuals with spina bifida, children undergoing surgical procedure during the neonatal period and individuals who required frequent surgical instrumentations. Latex allergy is also an important medical issue, particularly for healthcare personnel. Sensitization mainly occurs by wound or mucosal contact with latex devices during surgery or by inhalation of airborne allergens released from powdered latex gloves. Regarding diagnosis, the medical history, skin prick test and search for specific serum IgE are crucial but cost effective. The development of a guide listing latex-containing drugs is essential for the primary prevention of allergic reactions. Immunotherapy or specific premedication seems not effective in preventing the risk of anaphylaxis during the perioperative course. The most effective strategy to decrease the incidence of latex sensitization is complete avoidance. This strategy is efficient in patients and also in health care workers and has been applied since 2002 in our pediatric surgical hospital. One of major problem with the latex-free gloves was that surgeons find them considerably more difficult to work with. But today, manufacturers made considerable effort and free-latex gloves with an equal tactile sensation than the latex-gloves are now available. The extra cost of free latex gloves is well counterbalanced as allergen test, long stay hospital for allergic reaction, and worker's compensation are no longer needed. Since the introduction of this program in our institution, no allergic reaction to latex has been reported in 25000 anesthetized children or with the health care workers.     

Latex allergy in pediatric surgery is dependent on repeated operations in the first year of life

BACKGROUND/PURPOSE:Patients with spina bifida represent the highest risk group for hypersensitivity to latex. Recognized risk factors for these patients are repeated surgery and an atopic disposition. Little is known about children operated on in the first year of life for reasons other than spina bifida. METHODS: Eighty-six patients (mean age, 10.2 years) with gastrointestinal or urologic surgery were investigated for the number, type, and date of surgical interventions. Additionally, skin prick tests and provocation tests were performed to classify sensitized and symptomatic latex-allergic individuals. RESULTS: Twenty-seven patients were regarded as sensitized to latex (31.4%). Twenty patients were classified as being atopic (25.6%). Atopic patients were significantly more often sensitized and provocation positive compared with nonsensitized and provocation-negative ones (P <.01). Children already operated on in the first year of life (n = 44) with a positive provocation showed significantly higher latex-specific IgE-values than individuals with a negative outcome (P <.0001). The total number of operations and degree of sensitization showed a significant correlation; more than 8 surgical interventions during the first year of life significantly increased the risk of clinically relevant allergy to latex. CONCLUSION: This study emphasizes that individuals undergoing surgical interventions during infancy should be handled latex free from the very beginning of life.     

Latex anaphylaxis causing heart block: role of ranitidine

PURPOSE: Treatment with H2 receptor antagonists may cause the heart to be more susceptible to atrioventricular conduction delay when exposed to an overwhelming insult by histamine released during an anaphylactic reaction. We present the case of a woman, pretreated with ranitidine, who developed 3:1 heart block secondary to latex anaphylaxis. We propose that H2 antagonist premedication alone in patients susceptible to anaphylaxis increases their risk of heart block. CLINICAL FEATURES: A 38 yr old obese woman with cervical cancer presented for a radical hysterectomy. Systems review yielded a history of sleep apnea, orthopnea, gastroesophageal reflux, and sciatica. Medications included preoperative ranitidine, 150 mg. There was no history of atopy or allergy. Following general anesthesia induction, at the onset of the surgical procedure the patient developed a severe anaphylactic reaction which was heralded by the onset of 3:1 heart block, with decreases in SpO2, P(ET)CO2 and a decrease in systolic blood pressure to 45 mmHg. This was diagnosed as a possible latex reaction and treated using epinephrine boluses and infusion, fluids, 50 mg diphenhydramine, 50 mg ranitidine and 100 mg hydrocortisone. Following a 48 hr stay in the ICU the patient made an uneventful recovery. Allergy testing with intradermal latex injection and increased plasma tryptase levels confirmed a latex anaphylaxis. CONCLUSION: The use of H2 antagonists alone as a prophylaxis for gastroesophageal reflux may increase the risk of heart block in patients who develop anaphylaxis.     

Latex anaphylaxis during tissue expander insertion in a healthy child

Purpose

To report intraoperative latex anaphylaxis that occurred in an otherwise healthy child. Although latex anaphylaxis is seen in patients with myelodysplasia, genitourinary anomalies, sensitised healthcare workers, and patients with frequent exposure to latex, it has not been described in otherwise healthy children.

Clinical features

A nine-year-old girl developed intraoperative latex anaphylaxis manifested by increased airway pressure, expiratory wheezing, a decrease in oxygen saturation, severe hypotension and urticaria. The patient was treated with 5 μg·kg^?1 epinephrine iv and 5 mg·kg^?1 hydrocortisone iv. She required an epinephrine infusion of 0.4 μg·kg^?1 ·min^?1 and prolonged ICU admission. Her only previous latex exposure was during plastic surgical procedures. Latex allergy was confirmed weeks later using the prick method allergy testing.

Conclusion

Latex anaphylaxis can occur in otherwise healthy children whose only latex exposure occurred during a previous operation, including plastic surgery.     

Latex allergy in pediatric age: an interdisciplinary perioperative management and case reports

BACKGROUND: Latex intraoperative allergy is more and more frequent, especially in at groups risk (patients with spina bifida or congenital genitourinary abnormalities, pluri-operated patients, atopic subjects) and in pediatric age. The main problem of this allergy consists in the necessity of a strict collaboration of many specialists, in order to identify and safeguard the patient. METHODS: Our experience has pointed out an interdisciplinary perioperative management able to: 1. identify patients affected by latex allergy; 2. submit them to a latex-safe perioperative proceeding; 3. check their conditions with periodical tests. Selecting patients through a history and a list of questions, identifying profiles of typical risk patients, organizing the operating room with latex-free materials and equipment were the most important issues. Since November 1997 to December 1999 eighteen latex-safe perioperative proceedings have been carried out on 8 subjects (2 with esophageal atresia, 4 with bladder exstrophy and 2 with cloacal exstrophy); 2 of them were emergency cases. RESULTS: No allergic reactions and no proceeding-linked complications have been registered. Operators have always been satisfied by materials and equipment. Anesthesiological and surgical times resulted equal to those without latex-safe management. CONCLUSIONS: This perioperative management of potential or verified latex allergic patients turned out to be valid, safe and easy in practical application.     

Latex allergy. An not rare intraoperative event

Latex allergy has become a real problem among both surgical staff (paramedics and physicians) and patients especially pediatric patients with urogenital malformations and spina bifida. Latex allergy is produced from both natural molecules which compose the substance produced from Hevea brasiliensis (rubber tree) and industrial additives contents in latex devices. Diagnosis of latex allergy may be carried out through a preoperative Prik-test. A characteristic of latex allergy reaction is the starting of symptoms (more than 15 minutes after allergen contact). Pathophysiology of latex allergy is the same of all allergic reactions; it is an antigen-antibody reaction and type I or II reaction may occur. There are a lot of devices that surgeons and anesthesists use in the operative theatre and that should not be used in presence of a patient with latex allergy. Guaranteed latex-free devices should always be present in store.     

Latex allergy in children with oesophageal atresia

Background: Latex allergy is frequently found in children and patients with spina bifida and urogenital abnormalities and have been considered at risk for latex sensitization. The aim of the study was to evaluate the incidence of latex sensitization in patients with oesophageal atresia and undergoing three or more surgical procedures and to identify possible risk factors in the process of latex sensitization. Methods: A total of 20 patients were analysed: 19 boys and one girl. The oesophageal atresias were as follows: type I in three children, type II in two and type III in 15 children. Surgical and anaesthetic procedures, intensive care management, age, type of oesophageal atresia, associated congenital malformations, Waterston and Montreal prognostic classifications were considered as risk factors that may be implicated in the process of sensitization. Results: Five patients (25%) were considered sensitized to latex (group 1) and 15 (75%) nonsensitized (group 2). Among the five sensitized patients, three reported clinical reactions to latex, while the other two presented only specific IgE sensitization. The number of operations, the total hours of surgery, the number of drainages, the total days of drainage, the total days of central venous catheter were significantly greater in group 1 than in group 2. Both of the highest risk oesophageal atresia classes (Waterston C and Montreal II) were related to latex allergy. Conclusions: Oesophageal atresia, especially in cases of prolonged management, must be considered as a risk for the development of latex allergy.     

Anaphylactic reactions during cesarean section

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.